Directions:With your partner in a prone position, orient yourself to the triangular boundaries of the sacrum. Palpate the midline of the sacrum, which will bisect this triangle, as well as the articulations of the sacroiliac joints. The examiner may also follow the spinous processes of the lumbar spine inferiorly, whereby palpating inferior to the spinous process of L5 will give rise to the posterosuperior aspect of the sacrum.
Muscles That Attach Here:The sacrum serves as the proximal or distal attachment for numerous muscles and ligaments in the lumbopelvic region. Refer to the corresponding content on the hip and spine for further details about structures that attach to this location.
Structures That Attach Here:Sacroiliac ligaments, sacrotuberous ligament, sacrospinous ligaments
Coccyx
How to Palpate
Position of Partner: Prone
Directions: With your partner in a prone position, palpate inferiorly along the medial sacral crest toward the superior gluteal cleft. Palpate the superior aspect of the coccyx and the lateral and inferior aspects of the coccyx as much as you are able.
Muscles That Attach Here: Ischiococcygeus, levator ani muscles, gluteus maximus
Structures That Attach Here: Sacrospinous ligament, sacrotuberous ligament, sacrococcygeal ligament
Ilium
Iliac Crest
How to Palpate
Position of Partner: Standing, side-lying, supine
Directions: The iliac crest may be appreciated along three different pathways: 1) palpate the anterior superior iliac spine and slide posteriorly along the crest, 2) palpate the posterior superior iliac spine and slide anteriorly along the crest, and 3) locate the mid-axillary line of the body, and, at this line, move inferiorly from the ribs, or move superiorly from the greater trochanter, to meet the apex of the iliac crest.
Muscles That Attach Here: Iliacus, quadratus lumborum, external oblique, and tensor fascia latae
Iliac Fossa
How to Palpate
Position of Partner: Supine, hook-lying
Directions: Locate the anterior superior iliac spine and palpate superiorly and posteriorly along the inner rim of the iliac crest. The depth of your palpation will depend on the pliability of tissue in the area and your partner’s tolerance of the palpation.
Muscles That Attach Here: Iliacus
Anterior Superior Iliac Spine
How to Palpate
Position of Partner: Supine, standing
Directions: Place your hand at the lateral aspect of the abdomen at the mid-axillary line, below the umbilicus. From here, find and follow the iliac crest anteriorly until the anterior superior iliac spine is appreciated. This will be the most prominent skeletal landmark on the anterior hip.
Muscles That Attach Here: Sartorius, tensor fascia latae
Structures That Attach Here: Inguinal ligament
Anterior Inferior Iliac Spine
How to Palpate
Position of Partner: Supine, standing
Directions: Begin by locating the anterior superior iliac spine. Next, palpate inferiorly and slightly medially to the anterior inferior iliac spine.
Muscles That Attach Here: Rectus femoris, iliacus
Posterior Superior Iliac Spine
How to Palpate
Position of Partner: Prone, standing
Directions: Place your hands at the mid-axillary line on the superior aspect of the iliac crest. Follow the iliac crest posteriorly toward the sacrum. Palpate the bony spine of the posterior superior iliac spine at the end of the iliac crest.
Muscles That Attach Here: Lumbar multifidus
Ischium
Ischial Tuberosity
How to Palpate
Position of Partner: Prone
Directions: Identify the gluteal fold, or sulcus, between the buttocks. Palpate medially and superiorly from the midpoint of the gluteal fold until the ischial tuberosity is appreciated. You could also approach this structure by moving inferomedially from lateral hip structures, such as the greater trochanter, to palpate this landmark. Although a great deal of musculature and soft tissue may cover this skeletal landmark, it will still be prominent.
Muscles That Attach Here: Semitendinosus, semimembranosus, long head of biceps femoris, inferior gemellus, and quadratus femoris
Structures That Attach Here: Sacrotuberous ligament
Pubis
Pubic Crest
How to Palpate
Position of Partner: Supine
Directions: Palpate at the navel and move inferiorly along the midline of the abdomen until you palpate the bony ridge of the pubic crest. This will be the first skeletal landmark you feel when moving in this direction.
Muscles That Attach Here: Rectus abdominis, external oblique
Structures Located Near this Landmark: The inguinal ligament inserts next to the pubic crest at the pubic tubercle.
Superior Ramus
How to Palpate
Position of Partner: Supine
Directions: First, locate the pubic crest. Palpate laterally from the pubic crest along the anterior aspect of the ilium toward the anterior inferior iliac crest. Appreciate the superior ramus, which is located along the bony ridge lateral to the pubic crest.
Muscles That Attach Here: Pectineus
Femur
Greater Trochanter
How to Palpate
Position of Partner: Standing, supine, side-lying, prone
Directions: Locate the midpoint of the iliac crest along the lateral side of the body. Palpate inferiorly from this point toward the lateral aspect of the hip complex until the bony ridge of the greater trochanter can be felt. To confirm you are at the correct location, have your partner internally and externally rotate their hip while you continue to feel this area. With this motion you should be able to feel the bony ridge rolling underneath your fingers.
Muscles That Attach Here: Gluteus medius, gluteus minimus, piriformis, obturator internus, superior gemellus, inferior gemellus, and vastus lateralis
Gluteal Tuberosity
How to Palpate
Position of Partner: Prone
Directions: Orient yourself to the posterior aspect of the greater trochanter and palpate inferiorly along the lateral aspect of the femur until the tapering of the gluteus maximus muscle is felt. At the insertion of this muscle is the gluteal tuberosity on the femur.
Muscles That Attach Here: Gluteus maximus and adductor portion of adductor magnus
Origin(s): Anterior inferior iliac spine, ilium superior to acetabulum
Insertion(s): Base of patella via quadriceps tendon, indirectly via patellar ligament to the tibial tuberosity
Action(s): Knee extension, hip flexion
Innervation(s): Femoral nerve
How to Palpate
Position of Partner: Supine, sitting
Directions: Palpate along an imaginary line between the origin and insertion of the muscle. Appreciate the fibers of the muscle belly along this line. You may ask your partner to extend their knee or flex their hip to accentuate the muscle and its borders through this muscle contraction.
Vastus Lateralis
Origin(s): Greater trochanter, linea aspera
Insertion(s): Base of patella via quadriceps tendon, indirectly via patellar ligament to tibial tuberosity
Action(s): Knee extension
Innervation(s): Femoral nerve
How to Palpate
Position of Partner: Supine, sitting
Directions: Palpate superolaterally from the base of the patella into the muscle belly of the vastus lateralis. Instruct your partner to extend their knee to appreciate the muscle contraction and border of the vastus lateralis. You can also orient to this muscle on the lateral aspect of the thigh using the iliotibial tract/band. The vastus lateralis muscle will pass deep to this structure as it travels laterally.
Vastus Medialis
Origin(s): Intertrochanteric line, linea aspera
Insertion(s): Base of patella via quadriceps tendon; indirectly via patellar ligament to tibial tuberosity
Action(s): Knee extension
Innervation(s): Femoral nerve
How to Palpate
Position of Partner: Supine, sitting
Directions: Palpate superomedially from the base of the patella into the muscle belly of the vastus medialis. Instruct your partner to extend their knee to appreciate the muscle contraction and the border of the vastus medialis.
Directions: Locate the borders of the gluteus maximus via its proximal attachments, along the gluteal fold inferiorly, and to its distal attachments along the posterior iliotibial tract and gluteal tuberosity. Palpate superiorly from these borders to appreciate this muscle. Your partner may perform active hip extension, or a gluteal squeeze, to help you identify this muscle.
Gluteus Medius
Origin(s): External surface of the ilium between anterior and posterior gluteal lines
Insertion(s): Lateral surface of the greater trochanter
Action(s): Hip abduction, medial rotation
Innervation(s): Superior gluteal nerve
How to Palpate
Position of Partner: Side-lying
Directions: Palpate the greater trochanter along the lateral aspect of the hip and move superiorly toward the iliac crest to appreciate the anterior and posterior fibers of the gluteus medius along the outer aspect of the ilium. Your partner can perform active hip abduction to help you better appreciate this muscle.
Gluteus Minimus
Origin(s): External surface of the ilium between the anterior and inferior gluteal lines
Insertion(s): Anterior surface of the greater trochanter
Action(s): Hip abduction, medial rotation
Innervation(s): Superior gluteal nerve
How to Palpate
Position of Partner: Side-lying
Directions: Like the gluteus medius, palpate the greater trochanter, and gradually move superiorly along the anterior portion of the ilium on the lateral hip. Note that the gluteus minimus is located deep to the gluteus medius and has a similar location and orientation.
Sartorius
Origin(s): Anterior superior iliac spine
Insertion(s): Pes anserine
Action(s): Hip flexion, abduction, and lateral rotation and flexion of the knee
Innervation(s): Femoral nerve
How to Palpate
Position of Partner: Supine
Directions: Begin at the proximal attachment at the ASIS and palpate inferomedially along a diagonal to the medial aspect of the thigh toward the pes anserine. The pes anserine is located on the proximal tibia along the medial side. Instruct your partner to complete hip flexion, abduction, and lateral rotation, as if crossing their leg into a figure four position, to better palpate this muscle. In this position you may be able to distinctly feel the proximal end of the muscle as it contracts.
Adductor Longus
Origin(s): Body of pubis inferior to pubic crest
Insertion(s): Middle third of the linea aspera
Action(s): Hip adduction
Innervation(s): Obturator nerve
How to Palpate
Position of Partner: Supine
Directions: Broadly palpate the medial thigh and ask your partner to adduct their hip. As they actively perform this motion, preferably against resistance applied by the examiner’s opposite hand, palpate toward the pubic bone. Among the muscles of the medial compartment, palpate along the proximal attachment toward the distal attachment, appreciating the muscle belly of the adductor longus as it angles toward the linea aspera.
Adductor Magnus
Origin(s):
Adductor Portion: Inferior ramus of pubis and ramus of the ischium
Hamstring Portion: Ischial tuberosity
Insertion(s):
Adductor Portion: Gluteal tuberosity, linea aspera, medial supracondylar line
Hamstring Portion: Adductor tubercle of the femur
Action(s):
Adductor Portion: Hip adduction, hip flexion
Hamstring Portion: Hip extension
Innervation(s):
Adductor Portion: Obturator nerve
Hamstring Portion: Tibial nerve
How to Palpate
Position of Partner: Supine, side-lying
Directions: Begin by palpating at the adductor tubercle of the femur, and instruct your partner to adduct the hip against either manual resistance or gravity. Palpate the muscle fibers of the magnus by moving proximally, being mindful of bordering muscles of the medial thigh.
Gracilis
Origin(s): Body and inferior ramus of pubis
Insertion(s): Pes anserine
Action(s): Hip adduction, medial rotation, knee flexion
Innervation(s): Obturator nerve
How to Palpate
Position of Partner: Supine
Directions: Broadly palpate the medial thigh and ask your partner to adduct their hip. As they actively perform this motion, preferably against resistance applied by the examiner’s opposite hand, palpate along the proximal attachment, moving in a straight line distally toward its insertion at the pes anserine.
Pectineus
Origin(s): Superior ramus of pubis
Insertion(s): Pectineal line of femur
Action(s): Hip adduction, flexion, medial rotation
Innervation(s): Femoral nerve (potential for obturator nerve)
How to Palpate
Position of Partner: Supine
Directions: Place your partner’s leg of focus in a position of hip flexion and lateral rotation. You may orient to the region by identifying the adductor longus as described above. Slide superolaterally toward the anterior superior iliac spine and palpate deep to the pectineus. You may appreciate the muscle contraction of this muscle by instructing your partner to adduct their hip.
Tensor Fascia Latae
Origin(s): Anterior superior iliac spine, iliac crest
Insertion(s): Iliotibial band to the lateral condyle of the proximal tibia (Gerdy’s tubercle)
Action(s): Hip abduction, medial rotation
Innervation(s): Superior gluteal nerve
How to Palpate
Position of Partner: Supine
Directions: Palpate the anterior superior iliac spine and transition your hand toward the muscle belly by moving posteriorly and slightly distal to the anterior superior iliac spine. Instruct your partner to medially rotate or abduct the hip to appreciate the muscle belly.
Piriformis
Origin(s): Anterior sacrum, superior margin of greater sciatic notch, sacrotuberous ligament
Insertion(s): Superior aspect of greater trochanter
Action(s): Hip lateral rotation in positions of hip extension, hip abduction in positions of hip flexion
Innervation(s): Anterior rami of sacral nerves
How to Palpate
Position of Partner: Prone
Directions: Begin by locating the muscle’s distal attachment and palpating toward the proximal attachment by pressing deep into the gluteus maximus. Your partner may be cued to perform lateral rotation of their hip, with their knee flexed to 90 degrees, in order for you to better appreciate the muscle belly.
Deep Lateral/External Rotators
Obturator Internus
Origin(s): Obturator membrane
Insertion(s): Greater trochanter
Action(s): External rotation of extended hip, abduction of flexed hip
Insertion(s): Superior and Inferior: Greater trochanter
Action(s): External rotation of extended hip, abduction of flexed hip
Innervation(s): Superior: Nerve to obturator internus; Inferior: Nerve to quadratus femoris
Quadratus Femoris
Origin(s): Ischial tuberosity
Insertion(s): Intertrochanteric crest
Action(s): External rotation of extended hip, abduction of flexed hip
Innervation(s): Nerve to quadratus femoris
How to Palpate
Position of Partner: Prone, side-lying
Directions: The deep lateral rotators of the hip, including the piriformis, obturator internus, superior and inferior gemelli, and quadratus femoris, lie deep to the gluteal muscle groups in the posterolateral hip. Truly palpating these muscles is difficult due to the overlay of more dense, superficial gluteal musculature. Palpation of these structures is best performed with your partner in prone or side-lying position and following grossly from the insertion on the greater trochanter back toward each muscle’s origin.
Iliacus
Origin(s): Iliac crest, iliac fossa, ala of sacrum, anterior sacroiliac ligaments
Insertion(s): Tendon of psoas major and less trochanter of femur
Action(s): Hip flexion
Innervation(s): Femoral nerve
How to Palpate
Position of Partner: Hook-lying
Directions: Locate the anterior superior iliac spine and palpate superiorly and posteriorly along the inner rim of the iliac crest. The muscle belly will line the space previously palpated when locating the skeletal landmark of the iliac fossa.
Psoas Major
Origin(s): Lateral aspects of vertebral bodies of T12–L5, transverse process of T12–L5 vertebrae, lateral aspect of intervertebral discs
Insertion(s): Lesser trochanter
Action(s): Hip flexion
Innervation(s): Anterior rami of lumbar nerves
How to Palpate
Position of Partner: Hook-lying
Directions: Identify your partner’s navel and move approximately 2–3 fingerbreadths inferolaterally. Palpate deeply from anterior to posterior on the abdominal wall toward the muscle. Instruct your partner to perform ipsilateral active hip flexion, or perform hip flexion against resistance, to appreciate the contraction of the psoas major. The examiner must acknowledge that the specificity of this technique can be challenged given the distance between the anterior abdominal wall and the muscle and that you may be palpating over abdominal contents. Intra-abdominal pressure may also affect the success of this palpation.
Hamstrings
Biceps Femoris
Origin(s):
Long Head: Ischial tuberosity
Short Head: Linea aspera
Insertion(s): Head of fibula
Action(s): Knee flexion, hip extension
Innervation(s):
Long Head: Tibial nerve
Short Head: Common fibular nerve
How to Palpate
Position of Partner: Prone
Directions: First, palpate the superficial tendon of the biceps femoris from the head of the fibula. Have your partner flex their knee to make this tendon more pronounced. Of all the tendons of the posterior knee, this will be the most lateral tendon. Next, move superiorly toward the muscle belly on the lateral aspect of the posterior thigh to complete your palpation.
Semitendinosus
Origin(s): Ischial tuberosity
Insertion(s): Pes anserine
Action(s): Knee flexion, hip extension
Innervation(s): Tibial nerve
How to Palpate
Position of Partner: Prone
Directions: Palpate the superficial tendon of the muscle along the medial aspect of the knee. To note, the tendon of this muscle can also be distinctly palpated along the posterior knee. Although the gracilis muscle has the most medial tendon along the posterior knee, the semitendinosus tendon can be palpated next door, laterally, to the gracilis. Once you have located the tendon of the semitendinosus, follow the muscle proximally toward its origin by palpating the medial side of the posterior thigh.
Semimembranosus
Origin(s): Ischial tuberosity
Insertion(s): Posterior portion of medial condyle of tibia
Action(s): Knee flexion, hip extension
Innervation(s): Tibial nerve
How to Palpate
Position of Partner: Prone
Directions: Orient to the medial aspect of the knee via the semitendinosus. Attempt to palpate deep to the anterior and posterior aspects of the tendon of the semitendinosus to the semimembranosus. To note, the distal tendon of the semimembranosus is not distinctly palpable like the distal tendon of the semitendinosus. The muscle belly and tendon of the semimembranosus lie deep to the semitendinosus, which limits the specificity for palpation of this tissue alone.
Directions: Locate the distal attachment of this muscle by palpating the pubic crest. Slide just superiorly to this bony landmark to appreciate the tendon of the rectus abdominis inserting here.
Inguinal Ligament
How to Palpate
Position of Partner: Supine
Directions: Locate the proximal and distal attachments for the inguinal ligaments, which are the anterior superior iliac spine and the pubic tubercle, respectively. Begin by palpating this thin ligament at the anterior superior iliac spine and move inferomedially toward its distal attachment.
Directions: Locate the distal attachment at the lateral condyle of the proximal tibia (Gerdy’s tubercle), which is located on the proximal lateral aspect of the tibia. Then, palpate superiorly along the iliotibial band tissue at the level of the lateral femoral condyle. Along the distal aspect of the lateral thigh, the iliotibial band can be appreciated. Make sure to differentiate between the vastus lateralis tissue and biceps femoris tendon when palpating this structure.
Femoral Artery
How to Palpate: Palpate medially to the sartorius at its proximal end to feel the pulsing of the femoral artery. Located in this same area are the femoral vein and nerve.
When assessing flexion of the hip, the knee should be flexed in order to avoid any restrictions caused by tight hamstrings.
Hip Abduction and Adduction
When setting up your partner to assess all ranges of the hip, it’s important to think about what position may be best to yield the greatest range. For abduction and adduction, the side-lying position will be most helpful.
Hip Internal (Medial) and External (Lateral) Rotation
These ranges can be assessed by placing the lower limb in several different positions. You can have your partner lie in a supine position and then flex their hip to about 90 degrees, or they can be seated off the end of the table, where you can examine the range the lower leg arcs through during these motions.
Background: The patellar pubic percussion test is a useful clinical examination procedure for healthcare professionals to detect hip-related fractures that present with limited signs and symptoms. A patient is in supine position with their legs extended, and the examiner places the bell of a stethoscope on the patient’s pubic symphysis. Next, the examiner taps each patella, comparing the pitch and volume of the affected and unaffected sides. A decrease in sound on the affected side compared to the unaffected side warrants a referral for radiographic imaging. This osteophonic examination procedure has strong diagnostic utility.
Athletic Groin Pain
Background: Athletic groin pain is a broad term describing a collection of tissue structures responsible for pain felt in the inguinal region, where the inferior abdomen meets the proximal region of the thigh. This pain is typically experienced by individuals participating in multidirectional sports, such as football, soccer, and hockey. Healthcare providers will complete a patient history and physical examination to determine hip regions responsible for pain. Among other potential diagnoses, athletic groin pain may be categorized in the following groups: adductors, inguinal, pubic, and iliopsoas. Palpation, active and passive range of motion, and resistive testing are useful to differentiate among etiologies for groin pain.
Trendelenburg Gait (Compensated/Uncompensated)
Background: Trendelenburg gait is an abnormal gait pattern characterized by abnormal functioning of the hip abductor mechanism. This may occur for a variety of reasons, including pain and muscle weakness. The hip abductor muscle group, primarily the gluteus medius, is responsible for this gait feature. Abnormal function of the hip abductors can result in the inability to support the ipsilateral pelvis, which causes the pelvis to drop toward the contralateral side of the stance leg. To decrease the degree of pelvic drop, an individual may shift their weight onto the involved stance leg during stance. This is described as a compensated Trendelenburg gait.
Review Questions: Skeletal Landmarks of the Hip and Thigh
The is the origin of the iliacus muscle.
The anterior superior iliac spine is the bony attachment of which muscle(s)?
(True/False) The piriformis inserts on the lesser trochanter to facilitate internal rotation of the hip.
Describe how you might palpate the pubic crest on your partner.
The greater trochanter is located (medial / lateral) to the lesser trochanter.
The coccyx is located (medial / lateral/ inferior/ superior) to the sacrum.
The biceps femoris inserts on which of the following structures? (head of fibula / pes anserine/ tibial tuberosity)
Which three bones comprise the pelvis?
The inguinal ligament attaches to which two bony landmarks?
The pectineal line of the femur is the distal attachment site for (psoas major / pectineus / adductor longus /gracilis).
Review Questions: Musculature of the Hip and Thigh
Which three muscles comprise the pes anserine?
What is the action of the sartorius muscle?
(True/False) The obturator nerve innervates the adductor portion of the adductor magnus, and the tibial nerve innervates the hamstring portion of the adductor magnus.
A nerve injury to the femoral nerve would affect which of the following muscles? (rectus femoris / adductor magnus / piriformis / superior gemelli)
What is the action of the gluteus minimus muscle?
(True/False) The gluteus medius muscle is deep to the gluteus maximus muscle.
The hamstring muscle group facilitates (flexion / extension) at the hip joint, and (flexion / extension) at the knee joint.
Rectus femoris facilitates (flexion / extension) at the hip joint and (flexion / extension) at the knee joint.
Your partner reports pain with active knee flexion. If a muscle strain is responsible for this pain, which of the following muscles is most likely implicated in this scenario? (piriformis / sartorius / semitendinosus / iliopsoas)
The muscle insertion of the iliopsoas is (proximal / distal) to the muscle insertion of the adductor magnus.
